2008-04-03_REVISION - M1981138

• Permit No: M1981138
• IBM Index Class Name: REVISION
• Doc Date: 4/3/2008
• Doc Name: Conversion Submittal
• From: Baca County
• To: DRMS
• Type & Sequence: CN1
• Media Type: D
• Archive: No

-3-
T I. Correspondence Information:
APPL.ICANTlOPF,RA'.T'OR (name, address, and phone/~f name to be used on permit)
Contact'sNamc: ~~TLS/~ L.`~.1~W~Sc.?%~
Company Name:
Street/P.O. Box:
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1!`itie:.~AC/~ C~(JN7' l.P~~r SJ'~F~rl/b7L
1~.0. Box• /l'~i5~
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city: ~(l~L.. ~1EcfJ----- ~ __ ____-_--
State: _ ~ (b 2 ~ b O ~_~-__ ~ip Code: ~(~ 0 7 3
Telephone Number: ( 7~ ~ ) - _5~~~" ~os ~ ~.. ~___
Fax Number. ~ ~~ ~ ) - S~3 - ~ a I
PER.MITTTNG CONTACT (if different from applicant/o rator above) /~
~ ~ L~~4GL1l,~cr~yr ~-
Contact's Name: ~ FTLS/2 L ~ ®l~~S~N. "T"itle: ~Y ~ttlS1'/aN
Company Name: .~AC~ ~~H r,~ C~o+J ~
StreetiP.0. Box: 7 ~ ~ ~! p I N ~ I'~.0. Box; IY~~
City: Nlo~ d I
State: C ~ 'l.7 dip Code; ~l~ 7J
Telephone Number: ~ ~ / q ~ - SZ 3 ~
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Fax Number: ( ~ ~ ~ ) - S Z ~- //
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INSPECTION CON".CAGY
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4itle• ~AC~ ~HT~~1~irSi~/~'~.
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s Name:
Contact - ~
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Company Name: ~3 /~ O t~lT OJ '
StreedP.0. Box: ~y l /1'~/~ IN ~ P!.O. Box: -. ~
city: ~P2iN~ ~_~ ~~
State: ~yc~ ~ip Code: ~~3
't'elephone Number: ( 7~ ~ ) - ~2~- ~p .53~ _ i -..n
Fax Number:
CC_STATE OR FEDERAI, LANDOtiW FR if an !
Agency: _._._~
Street: ..._._.........._........._...........__.....__......._ ..............-----------------------L-----...._-------------°---__._._.._._..........-.__._----
C.rty: .. i.._...__._.__..._..._..__
Sta#e: __--Zl`ip t:ode:.._..._........._._-•----------__._......__..._.____..
't'elephone Number: C____....---.-----...--.~ - .---•---._......_.__.._..---__._.._._.__..._..._........._._......._....._.__. _.
..... ......._.-r---------------------------_-._......__.___._......._._.....-__.
CC?.,_STA7'E_OR. FEI)E:RAI, I..ANI)QWNIR (ifa~) ~
Agency: ---- - ---------------------- -;------
--
S[reet: _ -------------------~ ---
City:
State: ------ __.__._.. ~~P Cc>de:.__..._-----........_._._. _.-.~______
'T'el.e hone Number: _- _-- - -. i~._..._.___..__.._....,...._..._-.......__.__----------------_--.---